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The concept of child maltreatment, defined as harm to a child
because of abnormal child-rearing practices, is a broadening of
the initial description of the battered child syndrome. More than
1 million cases of child maltreatment are recorded yearly in the
U.S (Table 290-0.1). Child
maltreatment is an all-inclusive term covering physical
abuse; sexual abuse; emotional abuse; parental substance abuse;
physical, nutritional, and emotional neglect; supervisional neglect;
and Munchausen syndrome by proxy.1

The ease with which physicians are able to recognize these disorders,
in part, depends on their knowledge of normal children and normal
development. The physical stigmata of maltreatment are characteristic,
although the findings of neglect and sexual abuse are more subtle
than those of gross physical trauma.

Any serious injury in a child <5 years old, especially
in the absence of a witnessed event, should be viewed with suspicion. Other
injuries that may suggest child abuse include those the child states
were inflicted by another, were self-inflicted, or were inflicted
by an unknown assailant (Table 290-1).

The behavioral interaction between the child, the parent, and
the physician may provide supportive evidence of the diagnosis of
abuse (Table 290-2). Abused children are
often very compliant and submissive. They do not resist the medical
examiner and readily submit to painful procedures such as blood
drawing. They are overly affectionate to the medical staff, frequently
preferring the nurse or the physician to the parent. Sometimes,
they are protective of the abusing parent, try to cater to his or
her needs, and lie to cover up the true nature of the injury.